I’m concerned about Coronavirus and Stillbirth rates, but maybe not for the reasons that you might think.It has long been known that, whilst pregnant women are not necessarily more susceptible to viral illness, changes to their immune system in pregnancy can be associated with more severe symptoms should they happen to contract a viral illness when pregnant. That said the absolute risks of Covid-19 causing maternal or fetal morbidity or mortality are currently thought to be very small, in fact so small that at the moment that general consensus from professional bodies and Governments alike (see below) is that pregnant women are at no greater risk of contracting this virus than the rest of the general population.So while, of course, pregnant women need to take the same kinds of precautions as everyone else, they really don’t need to be treated any differently than anyone else. Which brings me to my next point.I say this to my midwifery students all the time “the ultimate pregnancy complication is death of either the baby or the mother and so the whole point of routine maternity care is to reduce the possibility of that complication. Reducing harm or injury to mother or baby is a neat side benefit, but we need to keep in mind that the whole aim of pregnancy care is to prevent death.”This is not just what I think. I quote from the RCOG website:Maternity care is essential, and has been developed over many years to reduce complications in women and babies. The risks of not attending antenatal care include harm to you, your baby or both of you, even in the context of coronavirus.

Now I come to my first cause for concern because changes are in fact being made to maternity care and this is occurring Globally. Let’s look at the kind of changes I am talking about. The RANZCOG website provides the following list for suggested changes to routine pregnancy care in Australia, including:

These changes mean that women are not currently being given care based on the Australian Governments recommendations. To point to but a few inconsitencies:

Now, of course we are in unprecedented times but these kinds of measures were developed and enacted broadly and quickly, without supporting evidence. They also supersede current pregnancy care guidelines which are all based on a WEIGHT of evidence, developed and refined over many years.So here are my concerns, or at least a few of them:

I’m worried that there will be a Global uptick in numbers of stillbirths in 2020 and that (God forbid) IF that were to occur that by the time we see it in statistics two or three years from now that it may be put down to the wrong cause i.e. directly linked to Covid-19 when it will be more likely to be indirectly linked to care provided during the Covid-19 outbreak.

I’m concerned that care providers are limiting contact with women during pregnancy based on their own fear and perhaps misguided concern to overprotect women such that essential maternity care developed over many years to reduce complications for woman and their babies is being substituted by our best guess care , without any apparent regard for the actual physical assessment and emotional support women and babies require during pregnancy.

I’m worried that pregnant women who have concerns about a change in their unborn baby’s movements may be even more reluctant than usual to access timely assessment of their baby's wellbeing from their care provider

Finally, as recently as today, Women and Birth (the journal of the Australian college of midwives” published an editorial titled “Midwives in a pandemic: A call for solidarity and compassion which had this to say :“Recent experience in Italy has shown that many pregnant women (especially women with previous loss) are really afraid of being COVID19 positive and feel insecure and anxious. This means that many women have an increased need for support and reassurance by all health care professionals, both during pregnancy and also during childbirth and puerperium”So, I ask my obstetric and midwifery colleagues: Do we really want to increase risk of known pregnancy complications such as hypertension, diabetes, preterm birth and stillbirth because we cant think of creative and safe ways to still properly care for our women?1: QLD Health (COVID-19 Guidance for Maternity Services).RANZCOG (Coronavirus (COVID-19)). The Lancet (What are the risks of COVID-19 infection in pregnant women?). The Royal Women’s Hospital (COVID-19: Advice for visitors and pregnant women)RCOGCovid 19 infection in pregnancy​

​While I am a BIG proponent of evidence based practice, it is also a source of frustration for me, especially those who want to wait for “more evidence” when the evidence we already have is sound, makes sense and aligns with our current knowledge of physiology and practice.One example from a few years back was when a midwife Tomasina Stacey reported findings from her PhD, a case-control study which examined risk factors for stillbirth (Stacey et al 2011). She stated that there was an increased risk of stillbirth if the mother described not settling to sleep on her side. This finding made sense, physiologically, practically and clinically. While some urged caution in adopting those findings into practice without subsequent study, midwives in New Zealand went ahead and started telling women to avoid supine sleep and low and behold there was a drop in stillbirth in that country that many have attributed to midwives telling women to sleep on their side (Mitchell 2015).Initially New Zealand was the only country in the world where maternity care providers gave this advice, obstetricians in other countries said we needed to wait for more evidence before “worrying women.” Now, almost a decade later, this recommendation has been adopted as one of the elements of the Australian version of the safer baby bundle, better late than never I suppose, but it is sad to think that in the ensuing 10 years many babies lives could have been saved by adopting this simple measure and this delay in adopting evidence into practice and waiting for the definitive study has undoubtably cost lives.Unfortunately, the same thing is happening again. This time with fetal movement messaging. We currently have a weight of evidence from good case-control and cohort studies that there are three aspects to how the unborn baby moves, these are :

Strength

Frequency

Pattern

BUT many maternity care providers seem to want to stick with old evidence and only tell women about decreases in frequency being important to report (eg Daly et al 2018).Actually, if you think about it, it isn’t rocket science. Once the baby is born and, in fact, for the rest of our lives we don’t use just one metric to tell us if a person is well or not. In fact, we all know that if a person is unwell they not only move less often, they move less strongly and will also usually change their pattern of daily activities. Frankly I don’t understand why its so very hard to accept the unborn baby does exactly the same thing!This evidence is from four case-control studies, ironically the same studies that gave us evidence that avoiding supine sleep in late pregnancy is probably a good idea. There has also been a good cohort study that has added evidence for how the well fetus behaves close to term (Bradford 2019). Yet for some reason this evidence hasn’t been accepted, apparently we need more.Its certainly baffling. The longer we wait to tell pregnant women the whole story, the longer we wont save every baby we possibly can in this country.Telling the pregnant women that getting to know her unborn baby movements is important and that IF she becomes concerned about any aspect of their behaviour (strength, frequency or pattern) that she should seek care, isn’t anxiety provoking …its empowering. I for one am not prepared to wait for those who think they need more evidence to get with the program, because pregnant women need every shred of evidence we have now to keep their baby safe, NOT evidence that we have cherry picked, NOT evidence we think wont make more work for us, NOT evidence we think is ‘safe’ to share…. ALL of it.What evidence am I talking about? Here is a summary of what we currently know about other changes in fetal movements:

As you look at these, tell me if the mother of a young baby reported any or all of the symptoms from the right hand column that you wouldn’t investigate further? !! Likewise if she was telling you symptoms from the left column… you would reassure her…right? Actually, taking that analogy further, no-one would even call for more evidence for this list of symptoms it’s so obvious that the symptoms on the right might indicate a problem and need to be investigated…right??Come on people its not rocket science, do we actually need to wait for even more studies that are saying the same logical thing or can we use our brains, our common sense and our conscience for that matter and tell women ALL signs she needs to be aware of AND report to keep her baby safe? ​

Australian Prime Minister Scott Morrison made what some in the media are calling a “gaff” when he said to a group of people on Kangaroo island “at least there hasn’t’ been any loss of life” when in fact two people had died on the island. The fact that he got this wrong is unforgivable but prefacing this sentence with “at least” also should be condemnedIt is in fact pretty common in tragic circumstances for victims to hear “at least”. In my experience after my daughter’s stillbirth it was “at least you know you can have children” “at least Emma wasn’t your first baby” “at least you didn’t get to know her”…and the awful “at least” example list goes on, and on! I know from person experience that it is never EVER helpful for a victim to hear sentences starting with “at least.”Lets imagine for a minute that even if Mr Morrison was right and there actually had not been a loss of any human lives, starting any sentence when talking to people who have been traumatised with “AT Least” is never EVER a helpful thing to do.Lets try some ridiculous examples to prove my point:Imagine someone has just lost their right arm in an accident would anyone, in their right mind , say “at least you have still got your left arm”Imagine if one of your friends mother’s just passed away would anyone say “at least you still have your father” ?So if you think about it even if Scott Morrison was right and there had in fact not been loss of human life on Kangaroo island does saying any sentence that starts with “at least” to a group of people who have just lost a great many things including, farm land, livestock, tourist livelihood, wildlife etc etc helpful? ABSOLUTELY NOT and so Mr Morrison needs to immediately and forever remove the two words “at least” from his vocabulary….in fact we all should.

According to AHPRA there are 744,437 registered health practitioners at 30 June 2019. Obviously not all would be working with pregnant women but you would think a fair chunk of the

33,434 midwives and 2,094 Obstetrician /Gynaecologists would... not to mention

Most of the 26,772 GPs who would usually have at least something to do with pregnant women even if its confirming the pregnancy, managing an acute illness during pregnancy, providing advice about quitting smoking, sleeping position or what to do about altered fetal activity, all important opportunities to discuss reducing stillbirth with pregnant women.

Also the students who are currently studying: Midwifery 4065, 248 a dual nursing /midwifery degree and 22,540 studying medicine

So a very rough estimate of “clinicians” who probably should access and complete the SBB e-learning resource is at least 89,153. So, while it is certainly a great start that 1,100 have completed the resource it represents around 1.2 % of those clinicians who should.Strategies for increasing clinician engagement with this vital new resource…anyone?

In a recent story titled “The biggest story in the UK is not Brexit. It’s life expectancy” published this week in “the Correspondent” author Danny Dorling (Geographer at the University of Oxford) points out that infant mortality is on a slow rise in England and Wales but declining in Scotland he saysThere has also been a rise in infant mortality. In England and Wales, this rise was concentrated in those same years of maximum public spending cuts. In 2014, 3.6 babies died for every 1,000 born. That rose to 3.7 in 2015, 3.8 in 2016, and 3.9 in 2017 (which sadly is the latest year for which we have data, as funding for ONS has also been cut).Though the change appears to be minuscule, according to the ONS, each rise was statistically significant. It means that enough extra babies died to increase that statistic by an amount that almost certainly did not occur by chance. Policy played a part – most importantly, policy concerning the funding of maternity units, the training of midwives, and the social services available to pregnant women. Most of the additional infant deaths each year occurred in the first few days or weeks of the child’s life.Scotland, by contrast, had the same infant mortality rate as England and Wales in 2014, but by 2018 it had been reduced to 3.2 per 1000 births. This too did not happen by chance. Having decided to invest in mothers and babies, the Scottish government diverted funds from other areas to ensure it did so.”It is very interesting that he puts the fall in infant mortality down to the Scottish Government “investing” in mothers and babies. One of the investments he is talking about is the establishment of the Maternity and Children Quality Improvement Collaborative (MCQIC), which enacted a quality standard that all maternity care providers have a documented conversation about the importance of fetal movements with pregnant women in the middle of pregnancy and at each antenatal visit thereafter. Supported by this MCQIC, Scotland has achieved a 22.5% improvement in the rate of Stillbirths since 2014.So, Dorling’s story rang some alarm bells for me because this year the Australian Government has invested a significant amount of money (over 5 million by some accounts) in the NHMRC funded Stillbirth CRE and their “Safer baby bundle” this is loosely modelled on England’s “Safe baby bundle v1”. A strategy that saw up to 20% decrease in stillbirth rate in some of the participating hospitals. Our Government has made this investment in the hope that we will see a similar decline in Stillbirth in hospitals that participate in our bundle. But if the infant mortality rate is slowly rising in England and declining in Scotland at a population level then surely we need to be also looking to what Scotland are doing to make change at a population level? This is particularly because the Scottish drop was NOT due to a bundle of care, that may or may not have been adopted by maternity care providers at the coal face, but a mandated quality and safety initiative enacted at Government level.Now I am not suggesting for one minute that the Safer baby bundle is not worth the Australian Governments investment. But these figures from the UK surely give us all cause to pause and consider what else needs to be done? These figures indicate that in order to achieve population level change that the SBB should NOT be the only thing the Australian Government does to try to reduce Stillbirth and that alongside the Bundle roll out urgent consideration also needs to be given to enacting Quality and safety standards just as Scotland did, because this seems to have been effective in reducing mortality at a population level rather than only at an individual hospital level.

Basically they have reported that Victoria’s perinatal mortality rate improved from 8.8 per 1000 births in 2017 to 8.6 in 2018, the lowest it has been for 18 years. This means there were 28 less baby deaths.

Enhanced training for specialists, monitoring of foetal (sic) growth issues and community education in a concerted statewide campaign by Safer Care Victoria and #movements matter campaigns are being credited for the result.

The Victorian Health minister Ms Mikakos weighed in with this:This is the most comprehensive approach to raise awareness of stillbirth risk factors and improve clinical practice and we are only getting started It is remarkable these efforts are already saving lives

It is indeed remarkable but also very unfortunate that the not-for-profit charity StillAware who have been working tirelessly away in Victoria, indeed across Australia has not been “credited” for making any contribution to this drop. This is especially sad because in the years 2014 to present they have delivered:

Education sessions to more than 1,316 maternity care providers in Victoria

I call upon those who are claiming credit for this fantastic reduction in stillbirth to immediately and loudly also attribute credit to the amazing efforts of StillAware, who have undoubtably also contributed to this drop AND without a single cent of assistance from the Victorian or Federal Governments.

As Mikakos says “Together we’re already saving lives and even before we see the data from our more recent efforts, we know that this too is making a difference.”

Yes together we are saving lives and it would be nice for herculean efforts like those made by StillAware to also be recognised

Which is more dangerous? Going over due or not listening to the mother?Today this story got me thinkinghttps://www.clactonandfrintongazette.co.uk/news/17982980.mums-campaign-daughter-stillborn-42-weeks/The story starts:A MUM whose baby was stillborn has launched a campaign to raise awareness of the dangers of being overdue.And tells the sad story of a mum who had a stillbirth at 41 weeks and mentions the mum did not know the "dangers" of going overdue. But the story also says :“We had a few bouts of reduced movement and went to Colchester Hospital a few times but they kept picking up movement”Now here is the thing and its important …. Just because the baby is moving does not mean it is well. Similarly, just because the baby has a heartbeat does not mean the baby is well.This mum knew there was something different and “few bouts” suggests that she presented with concerns multiple times so , in my opinion, the danger was not so much going overdue as not being listened to.My Daughter recently had her second baby. She was keen to have a VBAC and had a much better chance of achieving this if she went into natural labour. After 40 weeks, it would be fair to say, I was a little anxious about her risk of stillbirth BUT the thing that reassured me when I asked her about fetal movements was that she knew her baby's usual pattern and was confident she was well. AND she said things to me like "she is so active sometimes I think she has grown additional limbs" So what is the botom line here?If a mum is overdue and is confident that all is well then await labour BUT if the mum is overdue and has already presented multiple times concerned about her baby’s well-being then you are playing with fire to let her go overdue. What is needed for this to happen?The woman needs to be listened to and trusted. Yes maternity care providers can play their part and assess with CTG and ultrasound and blood tests which might even suggest that all is ok BUT if the mother isn’t reassured and happy to go home OR if she presents multiple times with concerns for heaven’s sake trust her and deliver her!

I have recently returned from the USA where one of the topics of concern is the 39 week rule. While there is rhetoric from ACOG that this rule has done no harm in fact there is much evidence that the opposite is true.

​Today a rather nice study of 15 million pregnancies provides some insight as to why the 39 week rule might be doing the harm that it is doing. This systematic review and meta—analysis showed clear increase in stillbirth risk from 38 weeks. Such that you have to think that if there is a line in the concrete at 39 weeks that this would inevitably mean increased risk of stillbirth.

While the numbers of babies potentially saved by “early term” delivery are admittedly small. This study does not support the rhetoric that 39 weeks is the new term and birth before this gestation will cause more harm than good.

It is very common for people to have a fatalistic view towards Stillbirth, as seen by these two examples of tweets in response to Senator Keneally's tweet about her party's commitment to reducing stillbirth should they win Government at the next election

While it is true that a certain proportion of all stillbirths are "more about mother nature" and try as we may we can never hope to prevent stillbirth altogether...at least not until we have figured out how to correct fatal fetal abnormalities before a stillbirth occurs BUT...there is no doubt we can lower the rate of stillbirth in this country.How can I be so confident? It has to do with knowing that when a Government sets its mind to reducing stillbirth that that is exactly what happens. How do I know this? Because it has worked in other high income countries like Scotland where there was a 20% reduction in stillbirth in Scotland when the Scottish Government funded a program to reduce stillbirth. How does funding help reduce stillbirth? Through education and awareness.Imagine for a minute if no-one knew the signs of an impending heart attack, and everyone just thought that deaths from heart attack were more to do with mother nature and there was nothing anyone could do to stop them...deaths from heart attack would go up ...right? Imagine also if we thought that SIDS deaths were inevitable...as we did in the 80s,.. and no-one knew to put their young baby to sleep on their backs, SIDS would go up again too...right?In much the same way some stillbirths can be prevented. Quite often a pregnant mum gets a warning that her baby is in trouble. In the 25 years since my baby Emma was stillborn I can't tell you how many times I've heard stories from parents of a stillborn baby that have made me incredibly cross because the mother noticed changes in her baby's activity or in her body , reported these changes to her care provider and was either falsely reassured or worse given incorrect advice. We can...and indeed we must....stop these deaths from happening. The Government spending money on public education and community awareness , alongside maternity care provider education will be effective in stopping these kinds of deaths. It is wonderful that we now have bipartisan commitment to do just that